Inspection on 27/06/07 for The Lilacs Resource Centre

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Lilacs Resource Centre 24/02/06

The Lilacs Resource Centre 09/11/05

The Lilacs Resource Centre 09/02/05

The Lilacs Resource Centre 26/07/04

The Lilacs Resource Centre 26/02/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Lilacs Resource Centre The Lilacs Resource Centre Warwick Road Scunthorpe North Lincolnshire DN16 1HH Lead Inspector Stephen Robertshaw Unannounced Inspection 27th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lilacs Resource Centre Address The Lilacs Resource Centre Warwick Road Scunthorpe North Lincolnshire DN16 1HH 01724 869635 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.northlincs.gov.uk North Lincolnshire Council Jacqueline Mary Campbell Care Home 30 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (6) The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Twenty four (24) in category DE(E) to be accommodated in units 3, 4 and 5 Unit 1 (Dove Suite) to only be used for Six (6) OP and/or PD(E) for the provision of intermediate care Only unit 2 lounge area may be used to accommodate up to 8 day care service users. Bedrooms in unit 2 May only be used to accommodate service users when the Commission has confirmed this area fit for purpose. The bungalow in the grounds may only be used to accommodate service users when the Commission has confirmed this area fit for purpose 24th February 2006 Date of last inspection Brief Description of the Service: The Lilacs is a purpose built home owned and managed by the local authority. It is situated near to the centre of Scunthorpe and close to local amenities, rail and motorway links. The home provides ground floor accommodation for a total of thirty service users. Twenty-four people, over the age of 65 years who may have needs associated with dementia, can be accommodated in the main unit and six people who have intermediate care needs in the Dove Suite. Day care is also provided for up to eight service users and there are people whose needs are met with regular respite breaks. The home is divided into five units. Unit one is the Dove Suite, a separate unit, which contains six en-suite bedrooms, a lounge, a bathroom and shower room, an assisted toilet and a rehabilitation kitchen. Unit two is mainly used for storage and offices and units three, four and five are for service users. All bedrooms are single and the main unit has two assisted bathrooms, an assisted shower room and eight single toilets throughout. In addition there are two lounges, a combined lounge/dining room and a separate dining room. There is also a designated smokers lounge and various smaller communal rooms for visitors, the hairdresser and therapies. The central garden space is accessible to service users and has been improved to make a more attractive area. The enclosed, paved area consists of a water feature, mature shrubs and seating. All areas of the home are accessible to The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 5 service users via wide corridors and ramps. The focus of the home has gradually changed and the home accommodates more short-term care such as respite and intermediate care. The fees for care provided at the home are determined through financial assessments that are completed by the local authority and are dealt with at a corporate location. Service users are notified of any contributions that they may need to make in relation to their fees before they are admitted in to the home. Previous inspection reports are made available to service users and visitors in the entrance of the home. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection included analysis of the information received by the Commission since the last key inspection. The site visit to the home took place on the 26th June 2007. The inspector was in the home for approximately six and a half hours and was made to feel very welcome by all of the service users, visitors and staff working in the home. The evidence provided for this report included a pre-inspection questionnaire that had been completed by the homes manager and returned to the Commission before the site visit took place and twenty questionnaires were sent to the staff and service users groups. Six staff surveys, and seven service users surveys were returned before this report was completed and elements of them have been included in the text of the report. The inspector also spoke with nine service users, seven family/ friends that were visiting the home and three professional visitors on the day of the inspection. What the service does well: What has improved since the last inspection? The recruitment procedures for the staff have improved. This means that the service users are kept safe from any form of abuse. All of the staff receive the The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 7 right safety checks before they are employed to work at the home and all of their previous work experiences were identified to show what knowledge and skills they had when working with older people. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that service users are provided with sufficient opportunities and information to enable them to form an opinion about if the home is right for them even in emergency situation. EVIDENCE: The inspector case tracked four of the service users that were resident in the home at the time of the site visit. Their care files all included a full assessment of their individual needs to make sure that they could be met through the services provided at the home. One of the service users had been admitted to the home a couple of days before the site visit in an emergency situation when her home became flooded and the Domiciliary Care Agency that provided service to her could not access her house. An up to date assessment and care plan was in position to demonstrate how her care needs should be met at the home. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 10 The assessments included nutritional, mobility and dexterity needs, however there was no evidence to support that these assessments had been evaluated on a regular basis to make sure that they were still appropriate to the needs of the service users. Following the assessment of need the home writes to the individual service users to inform them of the outcomes of the assessment. In one of the home comment books a prospective service user had stated that ‘the admission letters are wonderful, very helpful, I’m impressed!’ The home can clearly meet the needs of all of the service users in their care. Although the staff training and development to support this standard was not up to date interviews with staff, discussions with service users and visitors to the home and direct observation of the staffs interactions with service users and visitors confirmed that they have the necessary knowledge and skills to care for the service users. One service user commented to the inspector ‘the home and staff are ace, it’s like a home from home here’. In a recent survey one service user replied that the Lilacs was ‘highly recommended. I can’t fault it in any way’. The service users spoken to by the inspector were able to confirm that where appropriate they had been invited to visit the home before they had been admitted there to see if it would be suitable for them. One of the questionnaires returned to the inspector by a service user stated that they went it to the home because ‘a friend had told me about the Lilacs and how good and nice it was especially with the food’. The home provides intermediate care for six service users. They have a separate wing of the home that is made available to them. This included their own private and communal areas. At the time of the site visit most of the intermediate care service users were close to being discharged back home after successful rehabilitation periods there. An intermediate care user stated to the inspector that ‘it is wonderful (the Lilacs), they can’t do enough for you’ and added that ‘its very friendly and happy here’. The inspector observed the care file for one of the intermediate care service users. An assessment that should have been completed by the proper agency had not been completed. This means that the service users’ needs had not been clearly identified and appropriate care plans could not be developed. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the home has the capacity to meet the health and personal care needs of the service users. EVIDENCE: The inspector observed the care files for four of the service users and case tracked their care at the home. Three of their individual care files included care plans to identify how their needs should be met at the home to make sure that they remained appropriate to the needs of the individual service users. These need to be evaluated on a more regular basis due to the changing needs of most of the service users in the home and the need to implement new care plans to suit their needs. However where service users’ needs included skin integrity difficulties, there were no risk assessments or risk management plans to support the care plans. The other care file was for a service user that was placed in the service for short-term care. An assessment of their individual The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 12 care needs had not been completed and therefore it was difficult to identify if their care plan was appropriate to their needs. Where challenging behaviours were identified there were behaviour care plans in position. These could be improved by including more detail of how these behaviours affect the individual service users and link them more closely to the antecedents of any behaviour. The service users’ health care needs are met through various healthcare professionals that are based in the community including GP’s, hospital consultants, dentists, chiropodists and district nurses. The intermediate care service users also have access to health care professionals at the home including physiotherapists and occupational therapists. The manager stated to the inspector that they have developed very good relationships with the local GP practices. On the day of the inspectors visit to the service two GP’s visited the building unfortunately neither of them had time to speak to the inspector. An ambulance crew were also at the home at one point. The inspector spoke with them as they were preparing to transport a service user to the local hospital. They stated that the care staff had provided all of the information that they required to safely care for and transport the service user to hospital. All of the senior staff in the home had received accredited medication training. Most of the intermediate and short-term care service users self medicate. Clear risk assessments had been completed to make sure that this practice maintains the health, welfare and safety of the individual service users while they are resident in the home. The medication fridge was also checked. The insulin should have been stored between 2 degrees and minus 8 degrees centigrade. The fridge was recording three degrees centigrade. The management was requested to check with the local pharmacy if these medications were still safe to use and to ensure that all medication is appropriately stored. Direct observations supported the evidence that the service users’ privacy, dignity and respect are upheld at all times at the home. Service users stated to the inspector that ‘it’s wonderful here’, there are ‘plenty of staff’ who are ‘friendly and happy’ all of this supports the evidence that their dignity and respect is upheld. All of the service user spoken to by the inspector knew that they had care plans and care files at the home. One of the service users’ questionnaires confirmed that ‘I have been very well looked after by the staff’. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are encouraged to continue with any activities and hobbies that they had before they were admitted in to the home. EVIDENCE: The routines in the home were observed to be very flexible. Service users are provided with the choice of what time to get up from and retire to bed. This was confirmed through direct observation undertaken by the inspector and discussions with service users, visitors and care staff. A member of staff is being re-introduced to work following a period off work. As part of their development they have been allocated fifteen hours a week to develop the range and the frequency of activities that are made available to the service users. Notice boards in the home also included the advertisements for upcoming events to be held in the home. The activities are fairly stimulating, however they could be improved in relation the needs of service users with dementia. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 14 The inspector also spoke with six visitors to the service and they all confirmed that they are made to feel welcome any time that they visit the home. A community choir was also visiting the home at the time of the site visit. Several members of the group had visited the home previously and stated that the staff were always ‘welcoming’ and made them ‘regular drinks’. Two of the group also stated that they visit several different homes and the Lilacs was ‘one’ of their ‘favourites’. This was because the staff were ‘friendly’ and the environment was ‘very good’. The service users and visitors also confirmed that the home has a variety of communal areas that can be used for visits and that service users’ individual rooms can also be used if they prefer this for privacy. The home holds regular events to raise funds that are used to provide activities for the service users. The activity fund was well recorded and was up to date. All monies that are taken out of the account are fully receipted and audited. The inspector observed a mealtime at the home and ate with several of the service users. The food that was provided was well presented and was very tasty. The service users told the inspector that the meals were always ‘very good’ and seven service users also returned questionnaires to the inspector. All of these included comments of the good quality of food provided at the home. Staff were observed offering support to individual service users to enable them to eat their meals. This was seen to be done whilst at the same time upholding the dignity and respect of the service users involved. There were no special diets required by the service users in relation to cultural or religious needs, however some service users required low fat, low sugar or semi-soft meals. The cook stated to the inspector that if individual service users required any other special diets then she would be able to cater for their needs. The inspector also looked around the home’s kitchen. This was found to be very clean and was well organised. There were plenty of stores and these were all within the specified safety dates. All of the appropriate recordings were maintained in the kitchen for the temperature of meat when received, the temperature probes of all hot meals and regular temperature monitoring of the kitchens fridges and freezers. The home does not currently have a pay phone for the service users to access to contact their families and friends. The manager and care staff stated to the inspector that the home has wire free phones that the service users can access and identified that many of the service users have their own mobile phones. The home did not have any policies and procedures in position to support service users to contact their families and friends when a payphone is not available. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff protect the service users from possible abusive situations and receive appropriate adult protection training. EVIDENCE: The inspector observed the complaints and allegations records for the home. Since the last inspection there had been no formal complaints made in relation to the services provided at the home and no allegations had been reported to the local safeguarding adults team. No complaints or allegations had been directly reported to the Commission. Service users spoken to by the inspector were aware of the complaints procedure but stated that they had not had any cause to use the procedure. The complaints procedure was also available in the public areas of the home so that visitors to the home could also access it. There was evidence to support that the care staff were recruited appropriately with references and Criminal Record Bureau (CRB’s) checks, and their training records showed that they had received training in relation to the protection of vulnerable adults and how to manage challenging behaviour. The care practices were guided by robust adult protection policies and procedures as the home is part of the local authority and provide the appropriate training into the staff in relation to these policies. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 16 The management, senior staff and care staff that were interviewed by the inspector were aware of how to report suspected abuse and how investigation procedures would evolve. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is safe and suitable to the needs of the service users. However there are some areas that could be improved in relation to infection control. EVIDENCE: The inspector made a tour of the premises and found the home to be very clean and tidy. The outside areas of the home were a little untidy, however due to the recent bad weather problems the gardening staff had not had the opportunity to attend these areas. There are a variety of communal areas that the service users can choose to use to see their family, friends, and to interact with the other service users. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 18 The communal areas and the individual bedrooms were clean and had been pleasantly furnished and decorated. Those service users who resided at the home on a permanent basis had bedrooms that were personalised to their own tastes and preferences. Service users who were admitted for respite care tended to bring with them a range of their own items they required for the short stay including televisions and radios. The bedrooms had privacy locks and lockable facilities to keep their belongings safe. The Dove Suite provides intermediate care services. This is a relatively new unit and was furnished and decorated to a very high standard. Some service users have transferred from here to short term stays in the general environment of the home and these do not meet the same environmental standards of the Dove suite. All entrances to the home had ramps for wheelchair users and service users had access to inner secure areas. The home was a purpose built, ground floor unit and was suitable for its intended purpose. Hot water outlets accessible to service users had been fitted with thermostatic valves to ensure safety and prevent scalding. There are sufficient toilets and bathrooms in the home for the use of the service users. However at the time of the inspection two of the homes toilets were out of use. These had been reported to the maintenance team. Most of the bathrooms and toilets had blocks of soap left in them and one included a linen hand towel. This could cause infection control difficulties in the home. The staff training records identified that the care staff do undertake infection control training and the management and staff spoken to by the inspector were all aware of the policies and procedures for infection control in the home. Service users spoken to by the inspector and questionnaires returned to the inspector confirmed that the home was always clean and tidy. Several service users stated, ‘it’s like being at home’ and a visitor stated to the inspector ‘I have been to several different homes, but this one is the best for being clean and having lots of different areas to use for privacy’. The windows on the outside of the building need to have their restrainers adjusted to make sure that likely unwarranted entry to the home through these are restricted. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the staff have the necessary skills and knowledge to care for the service users, however some of their training to support was not up to date. EVIDENCE: There are sufficient staff on duty at all times in the home to meet the services commitments to the service users. There are no staff that are under twenty one working at the home. The home have recently achieved 50 of the care staff to have achieved NVQ 2 in care or equivalent. A further six staff are registered on the award and are working towards it. The home’s training records supported this information and also that appropriate induction and foundation training is provided for new staff. Five care staff returned their pre-inspection surveys back to the inspector. They were all very positive in relation to the support and training that they were provided with at the home. Service users spoken to were also very positive in relation to the staff group one commented that ‘the staff are very busy, but they are very good and always see to you as soon as they can’. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 20 The staff group working in the home is very consistent and most of the staff had worked in the home for a considerable length of time. They also confirmed to the inspector that they receive in excess of three paid training days per year. The recruitment procedures for the home make sure that the health, safety and protection of the service is upheld at all times. The staff personnel files provided evidence that the staff appointments support equal opportunities. The staff training records and interviews with management and care staff at the home showed that not all of the staffs mandatory training is up to date. The manager stated to the inspector that the training department of the local authority were instigating a rolling programme of training for residential care staff to make sure that all of their training is maintained and kept up to date. Direct observations supported the evidence that the care staff have the necessary knowledge and skills to understand and care for the needs of the service users. Service users spoken to by the inspector commented on the staff. Some of these comments included ‘they are very good’, ‘they listen to you’, the staff are always busy but keep happy’. There were no negative comments received from anywhere in relation to the qualities and competencies of the homes staff. A visitor to the home commented to the inspector ‘I visit monthly, there are always plenty of staff around, they are very friendly and helpful’. The care staff files observed by the inspector showed that they had not received the recommended minimum for formal supervision and also did not meet the local authority’s minimum supervision requirements. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that in general the management of the home supports and understands the needs of the service users and the staff group. EVIDENCE: The manager of the home was not available throughout the inspection as she was involved in interviewing for new members of staff for the home. However the manager was available at the end of the inspection for the inspector to feed back his findings. The manager of the home has a formal social work qualification and has also completed a certificate in management and there are clear lines of The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 22 accountability and responsibility in the home. The manager of the home had up until recently been supporting the management functions of another care home owned by the local authority. This service has now appointed a new manager and the manager of the Lilacs can now dedicate the bulk of her responsibilities and time to the home. The management approach to the home provides an open, positive and inclusive atmosphere. The home’s quality assurance and monitoring system is suitable to the needs of the service. Questionnaires are sent out to service users, their families and outside professionals that are involved in the care of the service users living at the home. The returned questionnaires are analysed and an action plan is created to maintain or improve the services being delivered through the home. The service users in general are responsible to look after their own finances whilst they are in the home and have a safe lockable area in their bedrooms to keep their belongings. The inspector randomly checked the pocket money accounts for three of the service users living at the home and all of their records were up to date and had been accurately recorded. The records in the home and interviews with management and staff showed that not all of the staff have received the recommended minimum of six formal recorded supervision periods within the last twelve months (pro-rata). The manager of the home was aware that this standard had slipped from previous inspections and stated that plans had been implemented that would ensure that all staff would be brought up to date with their supervision and annual performance reviews within a short period of time. The home does not currently have a pay phone for the service users to access to contact their families and friends. The manager and care staff stated to the inspector that the home has wire free phones that the service users can access and identified that many of the service users have their own mobile phones. The home did not have any policies and procedures in position to support service users to contact their families and friends when a payphone is not available. The records for the maintenance and servicing of all of the equipment in the home were up to date and had been accurately recorded. The home did not have a copy of the homes fire and electrical systems safety certificates. The manager stated to the inspector that these are kept with the corporate property services department. The inspector stated that a copy should be held at the site so that evidence could support that these certificates were up to date and met the requirements of the home for health and safety. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The registered person must make sure that service users that display challenging behaviours have appropriate risk assessment and management plans to support them. This will minimise any risk to the individual service user and others around them. The registered manager should make sure that the care plans for the long-term service users at the home are evaluated on a more regular basis to make sure that they are still appropriate to the needs of the individual service users especially in relation to their dietary and mobility needs. The registered person must make sure that all medication is appropriately stored especially in relation to items in the medication fridge to support the health and safety of the service users. The registered person must make sure that infection control policies and procedures are DS0000033138.V295665.R01.S.doc Timescale for action 19/07/07 2. OP7 15.2 30/07/07 3. OP9 13.2 04/07/07 4. OP26 13.3 04/07/07 The Lilacs Resource Centre Version 5.2 Page 25 5. OP28 18.1a,c adhered to in the home. This means that blocks of soap and linen towels must not be left in communal bathrooms and toilets. The registered person must make sure that all of the care staff receive the appropriate mandatory training to support the care that they offer to the service users. 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The registered manager should make sure that all assessments of service users needs are regularly reassessed to ensure that they remain relevant to the needs of the service users. The registered manager should make sure that any skin integrity issues for service users are supported by risk assessment and management plans to minimise any risks to them. The registered manager should make sure that health abbreviations are not used in relation to the care of the service users at the home. The registered person should make sure that service users daily diary recordings are more consistent to help to identify any patterns of behaviours for individual service users and to support the individuals care plans. The registered person should develop a policy and procedure for the service users to use the homes telephone to contact their families and friends in the absence of a public telephone. The registered manager should make sure that the window restrainers are adjusted to protect the service users form other people accessing the home through the open windows. The registered person should make sure that all of the care staff receive the recommended minimum of six DS0000033138.V295665.R01.S.doc Version 5.2 Page 26 2. OP3 3. 4. OP7 OP7 5. OP13 6. OP19 7. OP36 The Lilacs Resource Centre formal supervision periods per year (pro-rata) to monitor that the care that they are providing to the service users is appropriate and the care staffs personal development needs are identified. The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Lilacs Resource Centre DS0000033138.V295665.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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